Fraud Analyst
2 weeks ago
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Role Summary:
As Fraud Analyst, Fraud Investigation Unit, within Payment Integrity FWA Team you will be directly supporting Cigna's affordability commitment within Cigna International's business.
This role is responsible for detecting and recovering FWA payments, creating solutions to prevent claims overpayment and future spend monitoring.
He/She will work closely with other PI team members, Network, Medical Economics, Data Analytics, Claims Operations, Clinical partners, Product and International Markets Special Investigation Unit (SIU).
Responsibilities:
Identify and recover FWA payments on claim submissions.
Ensure PI savings are tracked and reported accurately.
Create solutions and drive execution to prevent claims overpayment, unnecessary claim spend, and ensure timeliness and accuracy of PI claims review process.
Negotiation with providers contracted by Cigna or out-of-Network providers.Data-mining to reveal FWA trends and patterns.
Partner with Cigna TPAs on provider investigations.
Partner with Payment Integrity teams in other locations to share FWA claiming schemes.
Partner with Data Analytics team in building future FWA triggers automation.
Provide investigation reports to internal and external stakeholders.
Review leads received through our dedicated team mailbox.
Utilize data analytics tools to develop potential FWA investigations.
Maintaining and monitoring FWA cases, properly documenting all developments in claim file
Conduct outreaches to members and providers to aide in active investigations
Skills and Requirements:
You should enjoy working in a team of high performers, who hold each other accountable to perform to their very best.
Minimum of 2 years of health insurance or health care provider experience.
Knowledge of claims coding, regulatory rules and medical policy.
Medical/ paramedical qualification is a definite plus.
Critical mind-set with ability to identify cost containment opportunities.
Experience with data analytics tool(s) is a strong asset.
Excellent verbal and written communication, interpersonal and negotiation skills.
Ability to balance multiple priorities at once and deliver on tight timelines.
Flexibility to work with global teams and varying time zones effectively.
Confidence to deal with internal stakeholders and ability to work with a cross functional team.
Strong organization skills with the ability to juggle priorities and work under pressure to meet tight deadlines.
Fluency in foreign languages in addition to fluent English is a strong plus.
Hybrid Work Location
About The Cigna Group
Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life.
We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality.
Join us in driving growth and improving lives.-
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